Health Plan Weekly

Cigna Corp. — which made headlines earlier this year when it indicated patients could receive a monetary award if they switch from a high-priced psoriasis drug to a cheaper biologic — now appears to be making that strategy an official program, starting with a different drug.

In a recent press release, the insurer revealed that starting in July, two approved biosimilars for Janssen’s immunosuppressive drug Remicade (infliximab) — Avsola and Inflectra — will move to preferred status on its formularies. “With these updates, Cigna is taking concrete steps to help patients and plans realize the promise of alternative, clinically effective treatment options,” the company said.

Health plans will see the best results in treating substance use disorder (SUD) by adopting a risk-sharing, value-based contracting model with providers, experts say. According to executives from a health plan and an addiction treatment provider, fee-for-service contracting can create incentives for providers that work against best practices in SUD treatment.

“Substance use disorder treatment, for decades in our country, [has] grown up outside of the traditional health care system,” said Stephanie Strong, CEO of SUD treatment provider Boulder Care, in a June 22 virtual panel discussion at the AHIP Institute and Expo. “And often, a lot of the policies and outcomes…[have] been the result of a lot of misinformation about this condition and its treatment. For example, the prevailing sentiment is, if someone has addictive disease, send them to rehab or a[n inpatient] facility — which may be for 30 or 90 days — and expect a cure when someone returns.”

In Oklahoma, the most recent state to implement a Medicaid expansion under the Affordable Care Act, the state Supreme Court recently struck down a plan pushed by Republican Gov. Kevin Stitt to implement a managed care organization (MCO) model for the expanded program. Experts say that the decision, which is the result of a suit brought by health care providers, is likely to increase cost in the program and is reminiscent of a similar provider-driven effort to undermine an MCO program in North Carolina.

The Oklahoma Supreme Court’s ruling holds that Stitt was acting outside his authority in soliciting bids for MCO contracts, which were awarded to four insurers — Blue Cross and Blue Shield of Oklahoma, Humana Inc.’s Healthy Horizons, Centene Corp.’s Oklahoma Complete Health, and UnitedHealthcare — and set to start enrolling members on Oct. 1. The court found that the voter-approved initiative expanding Medicaid did not explicitly authorize a managed care system, and said that for such a system to be implemented, the state legislature would have to pass a bill creating a managed care program.

By 2034, the U.S. will be facing a shortage of 37,800 to 124,000 physicians, predicts a new report from the Association of American Medical Colleges (AAMC). While that estimate dropped slightly from what the AAMC predicted in last year’s report, industry experts say that the looming dearth of doctors is still a cause for concern — and health insurers can help mitigate it.

“If we don’t address the shortage, over time more and more people won’t be able to get all the care that they need in a timely fashion. That’s the bottom line,” says Michael Dill, director of workforce studies at the AAMC. “There are already millions of Americans who face that problem, and it’s just going to grow if we don’t address the shortage.”

✦ The combined organization created by a merger between Tufts Health Plan and Harvard Pilgrim Health Care will now be known as Point32Health. “Inspired by the 32 points on a compass, Point32Health represents the role the organization plays in guiding and empowering its members and making a meaningful impact across the health care industry,” per a press release. The parent company of the combined organization will be headquartered in Canton, Mass.

✦ More than 1.2 million people signed up for health insurance through HealthCare.gov between Feb. 15 and May 31, according to CMS. By comparison, 501,000 people signed up for coverage in 2020 in the same period of time and 359,000 did in 2019. The increased signups are possible because of a pandemic-related special en-rollment period that applies to all consumers — not just those with qualifying life events — and increased uptake is also likely due to more generous premium subsidies included in the American Rescue Plan Act.